A patient is experiencing an acute stress reaction, and you observe an increase in heart rate, rapid breathing, and muscle tension. Which physiological process is most likely occurring?
Activation of the parasympathetic nervous system
Decreased blood flow to muscles
Release of insulin
Activation of the sympathetic nervous system
The Correct Answer is D
A. Activation of the parasympathetic nervous system: The parasympathetic system promotes “rest and digest” responses, including slowed heart rate and relaxation, which are opposite to the observed acute stress signs.
B. Decreased blood flow to muscles: During acute stress, blood flow to muscles actually increases to prepare for rapid physical response. Decreased perfusion would impair the body’s ability to respond to stress.
C. Release of insulin: Insulin primarily regulates blood glucose levels. During acute stress, insulin secretion is often suppressed to allow elevated glucose for energy, making this unrelated to the immediate stress response.
D. Activation of the sympathetic nervous system: The sympathetic nervous system triggers the “fight or flight” response, leading to tachycardia, rapid respirations, increased muscle tone, and mobilization of energy stores. These physiological changes align with the signs observed in acute stress reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply a topical ointment and continue with the bath: Applying ointment without further assessment or orders can mask skin changes and delay appropriate intervention. Early pressure injury management requires evaluation and interdisciplinary planning rather than routine topical treatment.
B. Cover the area with a bandage to prevent infection: Covering the area without assessment, staging, or provider notification may be inappropriate and could worsen skin breakdown. Dressing selection depends on the stage of the pressure injury and underlying skin integrity.
C. Document the findings and report to the healthcare provider: Redness over the sacral area may indicate a stage 1 pressure injury and requires prompt documentation and reporting. This allows for early interventions such as pressure redistribution, skin protection, and care plan updates before major damage occurs.
D. Ignore it since it is a common issue in bedridden clients: Pressure injuries are never expected or acceptable findings. Ignoring early signs increases the risk of progression to deeper tissue injury and serious complications.
Correct Answer is D
Explanation
A. Focusing solely on physical symptoms and ignoring emotional needs: Palliative care addresses the whole person, including emotional, psychological, spiritual, and social needs. Ignoring emotional aspects does not align with palliative care principles.
B. Discontinuing all medications: Stopping medications without considering symptom management or quality of life can cause unnecessary suffering. Palliative care focuses on comfort, not indiscriminate discontinuation of treatments.
C. Encouraging the client to undergo aggressive curative treatments: Palliative care emphasizes quality of life and symptom relief rather than pursuing aggressive interventions when they may not provide meaningful benefit.
D. Managing the client's dyspnea and pain effectively: Symptom management, such as controlling dyspnea and pain, is central to palliative care. This approach prioritizes comfort, dignity, and quality of life for clients with advanced illness.
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